temas livres free themes
Waist circumference as high blood pressure predictor
in school age children
Circunferência da cintura como preditora da pressão arterial
elevada em escolares
resumo A hipertensão na infância está aumen-tando com a epidemia de obesidade infantil, o que tem incentivado estudos para identificar um bom marcador antropométrico dos níveis pressó-ricos aumentados. O objetivo do presente estudo foi identificar o melhor preditor antropométrico de risco de hipertensão arterial em crianças en-tre 8 e 10 anos de idade. Foi realizada avaliação socioeconômica e aferidos pressão arterial (PA), peso, estatura, circunferência da cintura (CC) e percentual de gordura corporal (%GC). Das 445 crianças que participaram do estudo, 50,1% eram do sexo feminino. A prevalência de obesidade de-finida pelo índice de massa corporal (IMC) foi 14,6%. A PA aumentada foi observada em 3,4% e 2,2% das crianças, considerando as classificações pré-hipertensão e hipertensão, respectivamente. As médias dos valores pressóricos correlaciona-ram-se significativamente com IMC, CC, e %GC e, após o controle da estatura, as correlações que se mantiveram significativas foram entre CC e pressão arterial sistólica (PAS) e CC e pressão ar-terial diastólica (PAD). A variável que apresentou maior poder preditivo da ocorrência de hiperten-são foi a CC. Os resultados indicam que na popu-lação estudada de crianças entre 8 e 10 anos de idade a CC é uma medida de valor superior para predizer PA aumentada.
Palavras-chave Hipertensão, Obesidade
pediá-trica, Composição corporal, Crianças abstract Childhood hypertension is becoming
more common with the increasing numbers of child obesity, which has encouraged new studies to identify a good anthropometric marker for high blood pressure levels. The objective this study was to identify the best anthropometric predictor of risk of hypertension in children between 8-10 years of age. The Children were evaluated for so-cioeconomic status and their blood pressure (BP), weight, height, waist circumference (WC) and percentage of body fat (PBF) were measured. The study included 445 children, of which 50.1% were females. The prevalence of obesity defined by body mass index (BMI) was 14.6%. Increased BP was found in 3.4% and 2.2% of the children, consid-ering the pre-hypertension and hypertension clas-sifications respectively. The arithmetic mean of BP value correlated significantly with BMI, WC and PBF. After height control, the correlations that were maintained significant were between WC and systolic blood pressure (SBP) and be-tween WC and diastolic blood pressure (DBP). The variable with the highest predictive power of the occurrence of hypertension was WC. The re-sults indicate that, in this population of children between 8 and 10 years old, WC is a measurement of higher value in predicting increased BP.
Key words Hypertension, Pediatric obesity, Body
composition, Children
Nilcemar Rodrigues Carvalho Cruz (http://orcid.org/0000-0003-0820-6604) 1
Pollyanna Costa Cardoso (http://orcid.org/0000-0002-2779-2912) 1
Thaisa Netto Souza Valente Frossard (http://orcid.org/0000-0002-5708-7325) 1
Fernanda de Oliveira Ferreira (http://orcid.org/0000-0002-5857-2824) 1
Stela Brener (http://orcid.org/0000-0002-9294-1902) 2
Antônio Frederico de Freitas Gomides (http://orcid.org/0000-0001-5540-2734) 1
Maria Anete Santana Valente (http://orcid.org/0000-0002-8914-0493) 1
Cibele Velloso-Rodrigues (http://orcid.org/0000-0002-4998-1765) 1
1 Universidade Federal de Juiz de Fora. R. José de Tassis 350, Vila Bretas. 35030-250 Governador Valadares MG Brasil. [email protected] 2 Fundação e Centro de Hemoterapia e Hematologia de Minas Gerais. Belo Horizonte MG Brasil.
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introduction
Blood pressure (BP) in childhood is a predictor of hypertension in later life, increases the risk for cardiovascular morbidity and mortality, and is associated with overweight1.
The latest figures estimate that between 42.5 and 51.8 million children and adolescents (0-19 years) in Latin America are overweight or obese, which represents 20 to 25% of this popu-lation. The prevalence of overweight in children of school age (5-11 years) ranged from 18.9 to 36.9% and it is estimated that 22.2 to 25.9 mil-lions these children are overweight or obese2.
Data from the of the Brazilian Institute of Geog-raphy and Statistics indicate that 1/3 of Brazilian children between 5 and 9 years old were diag-nosed with overweight3. At the same time, high
BP in childhood has increased with the epidemic of childhood obesity4 reaching a prevalence of
al-most 5% of children and adolescents5.
Taking into account the relation between overweight and BP disorders, some studies have been investigating the association between a variety of anthropometric parameters and BP levels. These studies aim to identify a more suit-able predictor for high BP in childhood and/or adolescence6-9. Association between SBP and/or
DBP and the waist-to-height ratio was observed among a sample of 3 to 4 years old children6. In
another study, SBP and/or DBP were found to be associated with body mass index (BMI) and waist circumference (WC) among 3 to 6 years old chil-dren8. In works that included in the study sample
7 to 10 years old children, association between the pressure levels and WC7,9, BMI and
waist-to-hip ratio7 as well as triceps and subscapular
skin-folds9 were found.
It is known that, in addition to excess weight, increased WC is a risk factor for metabolic com-plications in adulthood. In children, WC was ref-erenced be a good marker to investigate metabol-ic disorders, including hypertension in different age groups10-13, however, the evidence of the WC
as predictor for BP disorder among children is still limited. In this context, studies investigating the relationship of overweight/obesity and exces-sive abdominal fat with elevated BP in children, as performed by Choy et al.4, Colín-Ramírez et
al.1, Flores-Huerta et al.14, are necessary, given its
screening of potential hypertension, preventive health, and because it is an investigation still in-sufficiently explored and reported in children.
Our study evaluated the prevalence of excess weight and variations in BP measurements in
children aged between 8 and 10, who attend pub-lic and private schools in a Brazilian city. In or-der to identify the best anthropometric predictor of the hypertension risk in childhood, this work also evaluates the association of BP levels with the following anthropometric variables: BMI, WC and percentage of total body fat (PBF).
methods and materials sample
The study was conducted with children aged 8 to 10 years old enrolled in four public schools and three private schools of the city of Governa-dor Valadares, Minas Gerais, Brazil, from May to August 2015. The sample size was calculated for prevalence studies, considering the prevalence of both obesity and hypertension in childhood from estimated data on epidemiological study conducted with a population of Brazilian chil-dren3,15. It was stipulated 95% confidence, 4%
estimation error and a design effect of 1.2, since sampling was conducted in a double stage (first we randomly selected a school and then a class). The minimum sample size of 347 participants has been found and 10% was add to this num-ber in order to offset any losses that may occur during data collection, resulting in a total of 381 children.
To ensure the representativeness of the sam-ple, we used the stratified proportional sampling technique selecting proportionally children ac-cording to the proportion of enrollments in Gov-ernador Valadares city (68% of public schools and 32% of private schools). Uniform sampling was performed by age group, selecting the same number of children aged 8, 9 and 10 years. To re-spect the uniform distribution by age and pro-portion by type of schools, it was decided that it would be necessary to select at least 127 children in each age group, with 102 public schools and 25 private schools. A pilot study involving 60 chil-dren was conducted aiming to test instruments and evaluation procedures.
ethical concerns
The study protocol was approved by the eth-ics committee from Federal University of Juiz de Fora. Furthermore, written informed consent was obtained from parents or legal guardians, and the child’s interest in participating in the study was asked before the measures. The study
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was conducted in accordance with the guidelines of the Declaration of Helsinki.
The following inclusion criteria was used: absence of chronic disease or inadequate condi-tions for anthropometry, such as the use of pros-thesis, orthopedic cast, physical or neurological disability.
socioeconomic assessment
For socioeconomic assessment was sent to the participant’s home a questionnaire to be completed by parents of participating children, in which they informed the monthly family in-come and the mother’s educational level.
Subjective options for family income assess-ment were presented. Subjects family income was grouped into three categories: 1 - up to three Bra-zilian minimum wage (MW), 2- between three and five minimum wages, 3- greater than five minimum wages. Subjects mothers education was grouped into 3 categories: 1- never studied, incomplete or complete elementary education, 2- incomplete or complete secondary education, 3- incomplete or complete undergraduate or postgraduate education.
anthropometric, Body Composition and Blood Pressure evaluation
The sex and birth date of the evaluated chil-dren were previously obtained from the school records.
The evaluations were carried out at the school on a previously scheduled day during school hours and after a minimum rest period of 5 minutes before evaluation. During the rest, were collected personal data and evaluated by the researcher the skin color (black, white, brown, yellow, indigenous).
For the anthropometric evaluations, mea-surements of weight, height and WC were taken. Tanita BC 558® (Tanita Corporation of
Amer-ica, Arlington Heights, IL, USA) was used for weight measurement with 0.1 kg precision and height was measured with a portable Stadiom-eter Alturexata® with scale in millimStadiom-eters. The measurements were taken with the child wearing light clothes, barefoot, positioned upright and erect, and with arms outstretched along the body. BMI was calculated by dividing weight by height squared (kg/m²). We calculated the Z-score of BMI (EZBMI) and height (EZH), according to sex and age, using the World Health Organiza-tion’s international standard of child and
adoles-cents growth16, by Anthroplus software. Children
were considered overweight with BMI for age >score z +1 and ≤ score z +2; obese >score z +2. Low stature was considered score z < -2.
WC was measured to the level of the mid-point between lower margin of the last palpable rib and top of the iliac crest, using a non-elastic anthropometric measuring tape with an accura-cy of 1 mm. It was used the reference proposed by Taylor et al.17, by using the 80th percentile for the
excess abdominal fat classification.
The PBF was obtained by Tanita®, Ironman model, four-pole. The children were kept up-right, with minimum clothing. They informed data of sex and birth date. It was considered ex-cess body fat values of 30% and 25% for girls and boys, respectively.
For the BP evaluation we followed the pro-posal of the National High Blood Pressure Ed-ucation Program18. BP was measured using an
aneroid sphygmomanometer, and selected the appropriate cuff for arm circumference. BP was measured in the right arm, with the child sit-ting and quiet, after a rest of at least 5 minutes, it was performed two measurements of at least one minute of difference between each measure to prevent venous congestion and maintain vari-ability PA to a minimum. Thus, prehypertension and hypertension was defined as systolic blood pressure (SBP) and diastolic blood pressure (DBP) were greater than or equal to 90 and 95 percentiles for age, sex and height, respectively.
statistical analysis
Descriptive analyzes were performed of so-cioeconomic, anthropometric, body composi-tion and BP variables.
Categorical variables PBF, WC, EZBMI and BP were individually associated with income and education, using the chi-square test. The normal-ity of the data was verified using the Kolmogor-ov-Smirnov test.
Pearson correlation analyzes were conducted to verify the intensity and direction of the rela-tionship between the values of SBP and DBP, and anthropometric variables and body composition (EZBMI, WC, and PBF). Partial correlation was made between the SBP and DBP and waist cir-cumference, controlling the effect of stature, not to be a bias.
To investigate which variable showed greater predictive value of high blood pressure, was con-ducted a multinomial logistic regression analysis. This analysis was conducted considering as
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pendent variable the presence of prehypertension and hypertension, separated into three groups: hypertension, prehypertension and normoten-sive, considering the latter as a reference for com-parison with the other groups. The independent variables were EZBMI, WC, and PBF.
In order to investigate which variable would be more predictive of BP changes, the groups of hypertensive and pre-hypertensive children were separated and an analysis of binary logistic re-gression was conducted. This rere-gression was per-formed using the conditional method, remaining in the model only those variables that remained significant. The independent variables included in the model were EZBMI, WC and PBF.
results
The study was carried out in four public schools and three private schools. Initially 455 children from public schools and 141 from private schools were invited. However, 142 children were not in-cluded in the study because they did not have pa-rental consent, three because they had neurologi-cal deficits and six children were not interested in participating. The final sample was 445 children, of which 313 (70.3%) were children from public schools and 132 (29.7%) from private.
Overall, the prevalence of overweight and obesity (including severe obesity) defined by the EZBMI was 21.3% and 14.6%, respectively. As for the estimation of PBF, 24% of children had excess body fat. The WC was considered increased in 17.9% of the students. The low height and thin-ness showed low prevalence (0.2% and 1.3%, re-spectively).
The average SBP was 94.2 mmHg (SD = 6.42 mmHg) and DBP was 57.6 mmHg (SD= 5.94 mmHg). SBP and / or increased DBP was observed in 3.4% and 2.2% of children given the pre-hyper-tension and hyperpre-hyper-tension rankings, respectively.
Of the total sample, 242 (54.4%) were brown, 139 (31.2%) white, 61 black (13.7%) and 3 (0.7%) did not inform skin color. The preva-lence of hypertension was 3,3% in brown chil-dren, 1,6% in black children and 0,7% in white children. The occurrence of pré-hypertesion was 3,7% in the brown children, 3,6% in the white children and 16% in the black children, No sig-nificance differences were found in the preva-lence of hypertension in black, brown or white children (p = 0,480).
Of the total number of children evaluated in schools, 221 parents or guardians, (49.6%)
filled the socioeconomic questionnaire. Among the mothers who answered the questionnaire 36.6% have never attended school or, at most, have completed primary education; 45,7% have attended or completed high school level. The family income data showed that 76% of respon-dents received a value lower than 3 MW, 12,2% received from 3 to 5 MW and 11,8 received more than 5 MW. Of the total number of children who presented BP variation 63.6% had a monthly in-come of less than 3 MW. There was no significant association between BP and income (p = 0,347) or education (p = 208).
The mean SBP and DBP were significantly correlated with EZBMI, WC and PBF. The values found in correlation analysis are shown in Table 1. Considering the possible influence of height in WC it was performed a partial correlation between WC and BP by controlling the effect of height, which revealed that the correlations remained significant between WC and SBP (r = 0.189, p < 0.001) and WC and DBP (r = 0.221, p < 0.001). A significant correlation was found, using the chi-square test, between hypertension (yes vs. no) and WC (p < 0.001).
The multinomial logistic regression analysis revealed that, considering jointly the effect of EZBMI, WC, and PBF, the variable with the pre-dictive power of the occurrence of hypertension was the WC, and every centimeter over WC, ele-vated in 1.22 times the chance of the child being hypertensive (Table 2).
The variable that remained significant in bi-nary regression model was WC, indicating that this variable was the most predictive of the oc-currence of BP disturbances (Table 3).
Discussion
The high prevalence of overweight and obesi-ty in children is observed in several studies10,19-23.
A survey from 2008 to 2009 by the Brazilian Insti-tute of Geography and Statistics showed that the prevalence of overweight among Brazilian chil-dren aged 5-9 years increased from about 13.4% in 1989 to 33.4% in 2008. For the same period, obesity increased from 3.2% to 14.2%, reaching a prevalence of 13.6% and 12.2% in children aged 8 and 9 years old, respectively3. These results are
close to the one found in this study (14.6% of obese children). The results of the present study also match others national studies of school population, public and private school networks, which found prevalence of obesity of 12.4%24
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some evidence correlate childhood obesity with metabolic and cardiometabolic risk factors in adulthood26, or as early as possible, even during
childhood27,28, are a key determinant of BP in
children and adolescents29.
The WC is considered a central adiposity marker30 being also recommended as an
indica-tor of total body fat31. In a study with 680
chil-dren aged 7 to 11 years from a public school, Mazaro et al.32 reported increased WC values
(15.4%), number similar to the one found in the present work (17.9%). Melzer et al.33 verified
by WC measurement that, in their home-based study with 357 families of children aged 3 to 10, 30.5% of the children had abdominal fat accu-mulation and that it was associated with the
nu-tritional status of the child. Increased abdominal fat was also observed in 13.4% of 1408 children aged 5-10 who were enrolled in public school34
and in 9.3% of the 1253 students aged 7 to 17 from public and private schools25.
More recently, studies have been trying to determine, between anthropometric parameters, which is the best marker of metabolic abnor-malities26-28,35. Damasceno et al.36 affirmed that
there are indications of a significant association between the classification of children for EZBMI and WC, the correlation coefficient between the two measures is considered strong.
In the case of BP disturbances, several studies have investigated associations between anthro-pometric variables with BP in children in differ-ent age groups, and found increased risk of BP increase with increasing EZBMI5,15,19,28,29,37 and
WC1,4,10,19,38.
The identification of the best anthropometric marker of increased BP in children becomes fea-sible as routine in clinical practice, whereas BP measurement in children is not part of a univer-sal standard protocol as well as the considerable prevalence of hypertension among children with great variation depending on the degree of adi-posity, age and ethnicity6,17,19,29.
This study found a prevalence of 3.4% and 2.2% of phypertension and hypertension, re-table 1. Correlations between Z-score of body mass index, waist circumference and percentage of body fat with
blood pressure (average measurements) among children aged 8 to 10 years.
systolic blood pressure Diastolic blood pressure
r P-value r P-value
EZBMI 0.398 < 0.001 0.295 < 0.001
WC 0.459 < 0.001 0.326 < 0.001
PBF 0.335 < 0.001 0.284 < 0.001
EZBMI: Z-score of body mass index; WC: waist circumference; PBF: percentage of body fat.
table 2. Multinomial logistic regression considering blood pressure classification (Hypertension,
prehypertension or normotension) as dependent variable.
Or 95% Ci P-value
Prehypertension * inferior limit Upper limit
EZBMI 1.912 0.76 4.807 0.16 WC 0.991 0.876 1.121 0.89 PBF 0.981 0.846 1.139 0.80 Hypertension * EZBMI 0.503 0.163 1.558 0.23 WC 1.221 1.032 1.444 0.02* PBF 0.999 0.837 1.191 0.98
Reference: normotension. BMI = body mass index; WC = waist circumference; PBF: percentage of body fat.
table 3. Binary logistic conditional regression
considering blood pressure alteration as dependent variable and waist circumference as independent variable.
OR 95% CI p-value
WC 1.008* 1.041-1.1137 < 0.001
*Adjusted for the variables body mass index and percentage of body fat. WC: waist circumference.
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spectively. These values are smaller than the val-ues of 8.85% and 5.18% found by Reuter et al.24
in a study with 1950 Brazilian children and ado-lescents aged 7-18 years.
In this study, it was observed that both SBP and DBP correlated with BMI, WC and PBF. No-tably, the variable WC was better correlated with increased blood pressure, being observed an in-crease of 1.22 times the chance of the child be-coming hypertensive every centimeter increased in WC. Thus, an increase by five centimeters, for example, would present an increased chance for the child to become hypertensive of 6.1 times. Flores-Huerta et al.14 observed in 2029 Mexican
children and adolescents that the prevalence and the likelihood of high blood pressure were higher in those with increased WC compared to high BMI. The positive association between WC and BP was also confirmed in other studies with children or adolescents. Mazaro et al.32 found
in-creased BP values in 10.9% of the sample. They also observed association between elevated BP and increased WC. Souza et al.25 found high BP in
7.7% of the sample and a significant association of obesity, according to BMI and WC, with ele-vated BP. Burgos et al.7 found that WC correlated
positively with BMI and BP.
Pooled data analysis of eight major epide-miological studies involving more than 47,000 children, found that regardless of race, gender and age, the risk of increased BP was signifi-cantly higher for those in the BMI top percentile compared with lower BMI percentile5. Although
studies indicate a strong association between abdominal fat accumulation and overweight by BMI for age33, in this study the WC and EZBMI
did not show the same association with the BP. The influence of WC in BP remained significant regardless of BMI. These results are consistent with previous studies in various populations who also noted that the WC was more sensitive to indicate risk of increased BP when compared to BMI1,4,14. It was suggested that one of the
rea-sons that the WC identifies a greater number of children with elevated BP is better because it esti-mates the intra-abdominal fat, while BMI mainly estimates the total and subcutaneous fat14.
Evaluating Chinese children and adolescents 7-17 years of age, participants of the “National Surveys on Chinese Students’ Constitution and Health”, and analyzing those with normal BMI, it was found that Z-scores of SBP, DBP and the prevalence of high BP for boys and girls were significantly higher in the presence of abdom-inal obesity, defined by increased WC29. In fact,
studies suggest that abdominal obesity should be considered a determining factor in the increase in BP and a major factor contributing to the in-creased prevalence of hypertension in children and adolescents40. The WC is associated with
car-diovascular risk factors39 and it is a predictor of
hypertension risk in children and adolescents38.
These results indicate that children with nor-mal weight, but with abdominal obesity should be screened for risk of high BP because alone, BMI may not provide sufficient sensitivity to identify risk of hypertension. Thus, the mea-surement of WC should be seen as an additional tool for analysis of BMI to help identify high BP among children. Kavey et al.5 point out that, since
hypertension is an asymptomatic condition, the BP measurement should be routine for all health care for children starting from three years old.
Other factors not investigated in this study can be correlated to high BP in children. The higher sodium intake is correlated with increased SBP in Brazilian children aged 3-4 years6 and the
high consumption of processed and ultra-pro-cessed foods justify this excessive sodium con-sumption as well as energy suggesting risk devel-opment of obesity and associated diseases40,41.
Whereas childhood obesity and involved co-morbidities, including high BP are the main health concerns worldwide42 and which often
persists in future ages and causes serious con-sequences to health, more specifically to cardio-vascular health, populational screening studies should be encouraged through the use of mea-suring WC, which features low cost, practicality and is easy to perform. This study suggests that in addition to BMI, is included to measure the WC and hypertension risk analysis in children. In ad-dition, health promotion measures are necessary to encourage healthy eating and regular physical activity.
Limitations of this study include BP levels be-ing obtained by a sbe-ingle visit. In addition, some potential factors of BP elevation, such as sodium intake, a positive family history and investigation of the presence of genotypic variation were not included. These factors will be considered in fu-ture studies. Our sample of children is represen-tative of the children of eight to ten years, of both public and private schools of the Governador Va-ladares city, therefore not being representative of the Brazilian population.
The comparison of the results presented with other studies should be performed with caution as different references were used for WC analysis in populations of different ethnicities.
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ing the predictive value WC in increased BP risk assessment in children as well as the feasibility of its use, there is need for an international defini-tion of abdominal obesity in children in order to standardize the assessment studies. According to Monzani et al.43, the cut-off point should be set
according to the cardiometabolic risk to be used to identify children at high risk of cardiometa-bolic complications providing specific and im-mediate health interventions.
Conclusion
The results indicate that within the studied pop-ulation of children between 8 and 10 years old, WC is a measurement of higher value in predict-ing increased BP. It can be considered that the results presented in this study may contribute to future decisions regarding the use of the measure of WC as a marker of increased BP levels, thus in-dicating individuals with higher risk and in need of a proper assessment of BP levels.
Collaborations
NRC Cruz participated in the design of the study, analysis and interpretation of the data, and in the final writing. PCC Pires helped with data col-lection, drafting and revising the paper. TNSV Frossard assisted the design of the study and data collection. FO Ferreira worked on data analysis and interpretation. S Brener participated in the delimitation of the study. AFF Gomides worked on the study design and delimitation, and in the closing revision. MAS Valente worked on the study design and delimitation. C Velloso-Ro-drigues participated in the study design and de-limitation, and in the final writing and revising.
acknowledgments
The authors appreciate the cooperation of the Professors Ione Maria de Matos from Federal University of Juiz de Fora; we are grateful to the students who participated in the survey for their cooperation. We thank all participating families and school officials. We thank the Minas Gerais Research Foundation (FAPEMIG) and Financier of Studies and Projects (FINEP) by financial sup-port.
This work and the postgraduate scholarship granted to Nilcemar Rodrigues Carvalho Cruz was supported by Minas Gerais Research Foun-dation (FAPEMIG); the Scientific Initiation scholarships were financed by Federal University of Juiz de Fora, some equipments were granted to Financier of Studies and Projects (FINEP).
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Artigo apresentado em 13/03/2017 Aprovado em 14/08/2017
